Exam 3 Health Assessment

When taking the history on a patient with a seizure disorder, the nurse assesses whether the patient has an *aura*. Which of these would be the best question for obtaining this information? a. "Does your muscle tone seem tense or limp?" b. "After the seizure, do you spend a lot of time sleeping?" c. "Do you have any warning sign before your seizure starts?" d. "Do you experience any color change or incontinence during the seizure?"

ANS: "Do you have any warning sign before your seizure starts?" Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions are not correct regarding asking about an aura.

In obtaining a history on a 74-year-old patient the nurse notes that he *drinks alcohol daily and that he has noticed a tremor in his hands* that affects his ability to hold things. With this information, what should the nurse's response be? a. "Does your family know you are drinking every day?" b. "Does the tremor change when you drink alcohol?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor."

ANS: "Does the tremor change when you drink the alcohol?" Senile tremor is relieved by alcohol, although this is not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.

A 70-year-old woman tells the nurse that every time she gets up *in the morning or after she's been sitting she gets "really dizzy"* and feels like she is going to fall over. The nurse's best response would be: a. "Have you been extremely tired lately?" b. "You probably just need to drink more liquids." c. "I'll refer you for a complete neurologic examination." d. "You need to get up slowly when you've been lying down or sitting."

ANS: "You need to get up slowly when you've been lying or sitting." Aging is accompanied by a progressive decrease in cerebral blood flow. In some people this causes dizziness and a loss of balance with position change. These people need to be taught to get up slowly. The other responses are incorrect.

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the *Glasgow Coma Scale, which number indicates that the patient* is in a coma? a. 6 b. 12 c. 15 d. 24

ANS: 6 A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale. See Figure 23-59.

A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he: A.Has a snake phobia. B. Is a hypochondriac; snakes are usually harmless. C. Has an obsession with snakes. D. Has a delusion that snakes are harmful, which must stem from an early traumatic incident involving snakes.

ANS: A A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it.

During morning rounds, the nurse asks a patient, How are you today? The patient responds, You today, you today, you today! and mumbles the words. This speech pattern is an example of: A. Echolalia B. Clanging C. word salad D. perseveration

ANS: A Echolalia occurs when a person imitates or repeats anothers words or phrases, often with a mumbling, mocking, or a mechanical tone.

The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia? A. Global B. Brocas C. Dysphonic D. Wernickes

ANS: A Global aphasia is the most common and severe form of aphasia. Spontaneous speech is absent or reduced to a few stereotyped words or sounds, and prognosis for language recovery is poor. Dysphonic aphasia is not a valid condition.

During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? A. Man believes that his dead wife is talking to him. B. Woman hears the doorbell ring and goes to answer it, but no one is there. C. Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag. D. Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

ANS: A Hallucinations are sensory perceptions for which no external stimuli exist. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory.

A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurses best approach regarding this examination is to: A. Plan to defer the rest of the mental status examination. B. Skip the language portion of the examination, and proceed onto assessing mood and affect. C. Conduct an in-depth speech evaluation, and defer the mental status examination to another time. D. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.

ANS: A In the mental status examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity of the steps that follow. For example, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions.

During a mental status examination, the nurse wants to assess a patients affect. The nurse should ask the patient which question? A. How do you feel today? B. Would you please repeat the following words? C. Have these medications had any effect on your pain? D. Has this pain affected your ability to get dressed by yourself?

ANS: A Judge mood and affect by the body language and facial expression and by directly asking, how do you feel today? or how do you usually feel? the mood should be appropriate to the persons place and condition and should appropriately change with the topics

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patients level of consciousness would be: A. Lethargic B. Obtunded C. Stuporous D. Semialert

ANS: A Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not stimulated, and can be aroused when called by name in a normal voice but looks drowsy. He or she appropriately responds to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought. Spontaneous movements are decreased.

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurses best course of action? A- Perform a complete mental status examination. B- Refer him to a psychometrician. C- Plan to integrate the mental status examination into the history and physical examination. D- Reassure his wife that memory loss after a physical shock is normal and will soon subside.

ANS: A Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a persons behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury.

The nurse is assessing the mental status of a child. Which statement about children and mental status is true? A- All aspects of mental status in children are interdependent. B- Children are highly labile and unstable until the age of 2 years. C- Children's mental status is largely a function of their parents level of functioning until the age of 7 years. D- A child mental status is impossible to assess until the child develops the ability to concentrate.

ANS: A Separating and tracing the development of only one aspect of mental status is difficult. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mothers body. The other statements are not true.

The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding? A. Cognitive impairment B. Amnesia C. Delirium D. Attention-deficit disorder

ANS: A The Mini-Cog is a newer instrument that screens for cognitive impairment, often found with dementia. The result of an abnormal drawing of a clock and time indicates a cognitive impairment.

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply. A. Develops over a short period. B. Person is experiencing apraxia. C. Person is exhibiting memory impairment or deficits. D. Occurs as a result of a medical condition, E. such as systemic infection. Person is experiencing agnosia.

ANS: A, C, D Delirium is a disturbance of consciousness that develops over a short period and may be attributable to a medical condition. Memory deficits may also occur. Apraxia and agnosia occur with dementia.

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination because he said he fell and hit his head. During the examination, the nurse asks him to *use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger*. The nurse should suspect which of the following? a. Cerebral injury b. Cerebrovascular accident c. Acute alcohol intoxication d. Peripheral neuropathy

ANS: Acute alcohol intoxication During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The person's movements should be smooth and accurate. The other options are not correct.

To test for *gross motor skill and coordination of a 6-year-old child*, which of these techniques would be appropriate? a. Hop on one foot. b. Stand on his head. c. Touch his finger to his nose. d. Make "funny" faces at the nurse.

ANS: Ask child to hop on one foot. Normally a child can hop on one foot and can balance on one foot for about 5 seconds by 4 years of age, and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skill. Touching the finger to the nose checks fine motor coordination. Having the child make "funny" faces tests cranial nerve VII. It is not appropriate to ask a child to stand on his or her head.

The nurse *places a key in the hand of a patient and he identifies it as a penny*. What term would the nurse use to describe this finding? a. Extinction b. Astereognosis c. Graphesthesia d. Tactile discrimination

ANS: Astereognosis Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the person's ability to feel sensations on both sides of the body at the same point.

During a mental status assessment, which question by the nurse would best assess a persons judgment? A. Do you feel that you are being watched, followed, or controlled? B. Tell me what you plan to do once you are discharged from the hospital. C. What does the statement, People in glass houses shouldn't throw stones, mean to you? D. What would you do if you found a stamped, addressed envelope lying on the sidewalk?

ANS: B A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the persons response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the persons judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations, and the capacity for violent or suicidal behavior.

A patient repeats, I feel hot. Hot, cot, rot, tot, got. Im a spot. The nurse documents this as an illustration of: A. Blocking B. Clanging C. Echolalia D. Neologism

ANS: B Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns.

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of: A. Social phobia B. Compulsive disorder C. Generalized anxiety disorder D. Posttraumatic stress disorder

ANS: B Repetitive behaviors, such as handwashing, are behaviors that the person feels driven to perform in response to an obsession. The behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation.

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination? A- A patients family is the best resource for information about the patients coping skills. B- Gathering mental status information during the health history interview is usually sufficient. C- Integrating the mental status examination into the health history interview takes an enormous amount of extra time. D- To get a good idea of the patients level of functioning, performing a complete mental status examination is usually necessary.

ANS: B The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described, however, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.

During the history of a 78-year-old man, his wife states that he occasionally has *problems with short-term memory loss and confusion: "He can't even remember how to button his shirt*." In doing the assessment of his sensory system, which action by the nurse is most appropriate? a. The nurse would not test the sensory system as part of the examination because the results would not be valid. b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with an explanation of each test, making certain that the wife understands. d. Before testing, the nurse would assess the patient's mental status and ability to follow directions.

ANS: Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time. The nurse should ensure validity of the sensory system testing by making sure the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

A patient repeatedly seems to have difficulty coming up with a word. He says, I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs. The nurse will note on his chart that he is using or experiencing: A. Blocking B. Neologism C. Circumlocution D. Circumstantiality

ANS: C Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object.

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient? A. Please count backward from 100 by seven. B. I will name three items and ask you to repeat them in a few minutes. C. Please point to articles in the room and parts of the body as I name them. D. What would you do if you found a stamped, addressed envelope on the sidewalk?

ANS: C Additional tests for persons with aphasia include word comprehension (asking the individual to point to articles in the room or parts of the body), reading (asking the person to read available print), and writing (asking the person to make up and write a sentence)

12. The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: A. Administer the FACT test. B. Ask him to describe his first job. C. Give him the Four Unrelated Words Test. D. Ask him to describe what television show he was watching before coming to the clinic.

ANS: C Ask questions that can be corroborated, which screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. The Four Unrelated Words Test tests the persons ability to lay down new memories and is a highly sensitive and valid memory test.

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview? A- I sleep like a baby. B- I have no health problems. C- I never did too good in school. D- I am not currently taking any medications.

ANS: C In every mental status examination, the following factors from the health history that could affect the findings should be noted: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level, noting this level as the patients normal baseline and not expecting a level of performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits.

A patient states, I feel so sad all of the time. I cant feel happy even doing things I used to like to do. He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question? A. Have you had any weight changes? B. Are you having any thoughts of suicide? C. How long have you been feeling this way? D. Are you having feelings of worthlessness?

ANS: C Major depressive disorder is characterized by one or more major depressive episodes, that is, at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression. Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms.

During an examination, the nurse can assess mental status by which activity? A- Examining the patients electroencephalogram B- Observing the patient as he or she performs an intelligence quotient (IQ) test C- Observing the patient and inferring health or dysfunction D- Examining the patients response to a specific set of questions

ANS: C Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an assessment of an individuals behaviors, such as consciousness, language, mood and affect, and other aspects.

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? A. Mental status assessment diagnoses specific psychiatric disorders. B. Mental disorders occur in response to everyday life stressors. C.Mental status functioning is inferred through the assessment of an individuals behaviors. D. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).

ANS: C Mental status functioning is inferred through the assessment of an individuals behaviors. It cannot be directly assessed like the characteristics of the skin or heart sounds.

The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infants parents that the Denver II: A. Tests three areas of development: cognitive, physical, and psychological B. Will indicate whether the child has a speech disorder so that treatment can begin. C. Is a screening instrument designed to detect children who are slow in development. D. Is a test to determine intellectual ability and may indicate whether problems will develop later in school.

ANS: C The Denver II is a screening instrument designed to detect developmental delays in infants and preschoolers. It tests four functions: gross motor, language, fine motor-adaptive, and personal-social. The Denver II is not an intelligence test; it does not predict current or future intellectual ability. It is not diagnostic; it does not suggest treatment regimens.

A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____. A. Invent; within 5 minutes B. Invent; within 30 seconds C. Recall; after a 30-minute delay D. Recall; after a 60-minute delay

ANS: C The Four Unrelated Words Test tests the persons ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than the recall of personal or historic events. To the person say, I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them. After 5 minutes, ask for the four words. The normal response for persons under 60 years is an accurate three- or four- word recall after a 5-, 10-, and 30-minute delay.

The nurse is providing instructions to newly hired graduates for the minimental state examination (MMSE). Which statement best describes this examination? A. Scores below 30 indicate cognitive impairment. B. The MMSE is a good tool to evaluate mood and thought processes. C. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. D. The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

ANS: C The MMSE is a quick, easy test of 11 questions and is used for initial and serial evaluations and can demonstrate a worsening or an improvement of cognition over time and with treatment. It evaluates cognitive functioning, not mood or thought processes. MMSE is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness.

The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: A- Will have no decrease in any of his abilities, including response time. B- Will have difficulty on tests of remote memory because this ability typically decreases with age. C- May take a little longer to respond, but his general knowledge and abilities should not have declined. D- Will exhibit had a decrease in his response time because of the loss of language and a decrease in general knowledge.

ANS: C The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected.

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he: A. May display some disruption in thought content. B. Will state, I am so relieved to be out of intensive care. C. Will be oriented to place and person, but the patient may not be certain of the date. D. May show evidence of some clouding of his level of consciousness

ANS: C The nurse can discern the orientation of cognitive function through the course of the interview or can directly and tactfully ask, Some people have trouble keeping up with the dates while in the hospital. Do you know todays date? Many hospitalized people have trouble with the exact date but are fully oriented on the remaining items.

A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self- mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurses best response in this situation? A. Do you have a weapon? B. How do other people treat you? C. Are you feeling so hopeless that you feel like hurting yourself now? D. People often feel hopeless, but the feelings resolve within a few weeks.

ANS: C When the person expresses feelings of hopelessness, despair, or grief, assessing the risk of physical harm to him or herself is important. This process begins with more general questions. If the answers are affirmative, then the assessment continues with more specific questions.

During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas? A. My stomach hurts. Hurts, spurts, burts. B. Kiss, wood, reading, ducks, onto, maybe. C. Take this pill? The pill is red. I see red. Red velvet is soft, soft as a babys bottom. D. I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.

ANS: C Flight of ideas is demonstrated by an abrupt change, rapid skipping from topic to topic, and practically continuous flow of accelerated speech. Topics usually have recognizable associations or are plays on words.

Which term refers to a wound produced by the tearing or splitting of body tissue, usually from blunt impact over a bony surface? A. Abrasion B. Contusion C. Laceration D. Hematoma

ANS: C. The term laceration refers to a wound produced by the tearing or splitting of body tissue. An abrasion is caused by the rubbing of the skin or mucous membrane. A contusion is injury to tissues without breakage of the skin

A 30-year-old woman tells the nurse that she has been very *unsteady and has had difficulty in maintaining her balance*. Which area of the brain would the nurse be concerned about with these findings? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract

ANS: Cerebellum The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the main relay station where sensory pathways of the spinal cord, cerebellum, and brainstem for synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.

The nurse knows that determining whether a person is *oriented to his or her surroundings will test the functioning* of which of these structures? a. Cerebrum b. Cerebellum c. CNs d. Medulla oblongata

ANS: Cerebrum The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other options structures are not responsible for a person's level of consciousness.

A 50-year-old woman is in the clinic for *weakness in her left arm and leg that she has noticed for the past week*. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination

ANS: Complete neurologic examination The nurse should perform a complete neurologic examination on persons who have neurologic concerns (e.g., headache, weakness, loss of coordination) or who have shown signs of neurologic dysfunction. The Glasgow Coma scale is used to define a person's level of consciousness. The neurologic recheck examination is appropriate for persons with demonstrated neurologic deficits. The screening neurologic examination is performed on seemingly well persons who have no significant subjective findings from the history.

During an examination, the nurse notices a patterned injury on a patients back. Which of these would cause such an injury? A. Blunt force B. Friction abrasion C. Stabbing from a kitchen knife D. Whipping from an extension cord

ANS: D A patterned injury is an injury caused by an object that leaves a distinct pattern on the skin or organ. The other actions do not cause a patterned injury.

When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is: A- Presence of phobias B- General intelligence C- Presence of irrational thinking patterns D- Sensory-perceptive abilities

ANS: D Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 15) may result in apathy, social isolation, and depression. Hearing changes are common in older adults, which produces frustration, suspicion, and social isolation and makes the person appear confused.

A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of: A. Confusion B. Ambivalence C. Depersonalization D. Inappropriate affect

ANS: D An inappropriate affect is an affect clearly discordant with the content of the persons speech.

A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span? A. How do you usually feel? Is this normal behavior for you? B. I am going to say four words. In a few minutes, I will ask you to recall them. C. Describe the meaning of the phrase, Looking through rose-colored glasses. D. Pick up the pencil in your left hand, move it to your right hand, and place it on the table.

ANS: D Attention span is evaluated by assessing the individuals ability to concentrate and complete a thought or task without wandering. Giving a series of directions to follow is one method used to assess attention span.

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patients: A. Affect and mood B. Memory and affect C. Language abilities D. Level of consciousness and cognitive abilities

ANS: D Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. Delirium is not an alteration in mood, affect, or language abilities.

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that: A. She probably does not have any problems. B. She is only trying to shock people and that her dress should be ignored. C. She has a manic syndrome because of her abnormal dress and grooming. D. More information should be gathered to decide whether her dress is appropriate.

ANS: D Grooming and hygiene should be notedthe person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, and men are shaved or their beards or moustaches are well groomed. Care should be taken when interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the persons economic status or a deliberate fashion trend.

A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow- up assessment. The nurse will want to ask her which one of these questions? A. How are things going with the trial? B. How are things going with your job? C. Tell me about your recent engagement! D. Are you having any disturbing dreams?

ANS: D In posttraumatic stress disorder, the person has been exposed to a traumatic event. The traumatic event is persistently reexperienced by recurrent and intrusive, distressing recollections of the event, including images, thoughts, or perceptions; recurrent distressing dreams of the event; and acting or feeling as if the traumatic event were recurring.

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented? A. I know my name is John. I couldnt tell you where I am. I think it is 2010, though. B. I know my name is John, but to tell you the truth, I get kind of confused about the date. C.I know my name is John; I guess Im at the hospital in Spokane. No, I dont know the date. D.I know my name is John. I am at the hospital in Spokane. I couldnt tell you what date it is, but I know that it is February of a new year2010.

ANS: D Many aging persons experience social isolation, loss of structure without a job, a change in residence, or some short-term memory loss. These factors affect orientation, and the person may not provide the precise date or complete name of the agency. You may consider aging persons oriented if they generally know where they are and the present period. They should be considered oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identification of the type of setting (e.g., hospital) and the name of the town

As a mandatory reporter of elder abuse, which must be present before a nurse should notify the authorities? A. Statements from the victim B. Statements from witnesses C. Proof of abuse and/or neglect D. Suspicion of elder abuse and/or neglect

ANS: D Many health care workers are under the erroneous assumption that proof is required before notification of suspected abuse can occur. Only the suspicion of elder abuse or neglect is necessary.

The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girls mental status? A. She clings to her mother whenever the nurse is in the room. B. She appears angry and will not make eye contact with the nurse. C. Her mother states that she has begun to ride a tricycle around their yard. D.Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.

ANS: D The mental status assessment of infants and children covers behavioral, cognitive, and psychosocial development and examines how the child is coping with his or her environment. Essentially, the nurse should follow the same Association for Behavioral and Cognitive Therapies (ABCT) guidelines as those for the adult, with special consideration for developmental milestones. The best examination technique arises from a thorough knowledge of the developmental milestones (described in Chapter 2). Abnormalities are often problems of omission (e.g., the child does not achieve a milestone as expected).

A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, I buy obie get spirding and take my train. What is the best description of this patients problem? A. Global aphasia B. Brocas aphasia C. Echolalia D. Wernickes aphasia

ANS: D This type of communication illustrates Wernickes or receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well articulated, but it has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often, a great urge to speak is present. Repetition, reading, and writing also are impaired. Echolalia is an imitation or the repetition of another persons words or phrases.

Which of these individuals would the nurse consider at highest risk for a suicide attempt? A. Man who jokes about death B. Woman who, during a past episode of major depression, attempted suicide C. Adolescent who just broke up with her boyfriend and states that she would like to kill herself D. Older adult man who tells the nurse that he is going to join his wife in heaven tomorrow and plans to use a gun

ANS: D When the person expresses feelings of sadness, hopelessness, despair, or grief, assessing any possible risk of physical harm to him or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or she should continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high risk.

Which statement is best for the nurse to use when preparing to administer the Abuse Assessment Screen? A. we are required by law to ask these questions B. we need to talk about whether you believe you have been abused C. we are asking these questions because we suspect that you are being abused. D. we need to ask the following questions because domestic violence is so common in our society.

ANS: D Such an introduction alerts the woman that questions about domestic violence are coming and ensures the woman that she is not being singled out for these questions.

Which of these tests would the nurse use to check the *motor coordination of an 11-month-old* infant? a. Denver II b. Stereognosis c. Deep tendon reflexes d. Rapid alternating movements

ANS: Denver II To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a person's ability to recognize objects by feeling them, and is not appropriate for an 11-month-old infant. Testing of the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults.

A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of *Alzheimer's disease*? Select all that apply. a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in one's own neighborhood

ANS: Difficulty performing familiar tasks, such as placing a telephone call Misplacing items, such as putting dish soap in the refrigerator Rapid mood swings, from calm to tears, for no apparent reason Getting lost in one's own neighborhood Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one's own neighborhood can be warning signs of Alzheimer's disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. For other examples see Table 23-2.

The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is *unable to pat both her knees*. Her response is very slow and she misses frequently. What should the nurse suspect? a. Vestibular disease b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions

ANS: Dysfunction of the cerebellum When a person performs rapid, alternating movements, slow, clumsy, and sloppy responses occur with cerebellar disease. The other responses are incorrect.

When the nurse is testing the *triceps reflex*, what is the expected response a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearmse? not on powerpoint

ANS: Extension of the forearm The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.

In assessing a 70-year-old patient who has had a recent *cerebrovascular accident, the nurse notices right-sided weakness*. What might the nurse expect to find when testing his reflexes on the right side? a. Lack of reflexes b. Normal reflexes c. Diminished reflexes d. Hyperactive reflexes

ANS: Hyperactive reflexes Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.

In a person with an *upper motor neuron lesion such as a cerebrovascular accident*, which of these physical assessment findings should the nurse expect to see? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles

ANS: Hyperreflexia Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons. See Table 23-7.

A 59-year-old patient has a *herniated intervertebral disc*. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes

ANS: Hyporeflexia With a herniated intervertebral disk or lower motor neuron lesion there is loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia. No Babinski's sign or pathologic reflexes would be seen. The other options reflect a lesion of upper motor neurons. See Table 23-7.

During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: *pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light*. What does finding this suggest? a. Injury to the right eye b. Increased intracranial pressure c. Test inaccurately performed d. Normal response after a head injury

ANS: Increased intracranial pressure In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.

While gathering equipment after an injection, *a nurse accidentally received a prick* from an improperly capped needle. To interpret this sensation, which of these areas must be intact? Not on powerpoint a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

ANS: Lateral spinothalamic tract, thalamus, and sensory cortex The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas those of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.

The nurse is caring for a patient who has *just had neurosurgery. To assess for increased intracranial pressure*, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response

ANS: Level of consciousness, motor function, pupillary response, and vital signs Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.

During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to *relax his muscles completely. The nurse then moves each extremity through full range of motion*. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement

ANS: Mild, even resistance to movement Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretch. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.

During an assessment of the cranial nerves, the nurse finds the following: *asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek*. This would indicate dysfunction of which of these cranial nerves? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII

ANS: Motor component of VII The findings listed reflect a dysfunction of the motor component of cranial nerve VII, the facial nerve.

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the *patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae*. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex

ANS: Peripheral neuropathy Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome.

The nurse is testing superficial reflexes on an adult patient. When *stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes*. How should the nurse document this finding? not on powerpoint a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from "0 to 4+"

ANS: Plantar reflex present With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, like an upside-down "J." The normal response is plantar flexion of the toes and sometimes of the whole foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

To assess the *head control of a 4-month-old infant, the nurse lifts the infant up in a prone position while supporting his chest*. The nurse looks for what normal response? a. Raises the head, and arches the back. b. Extends the arms, and drops down the head. c. Flexes the knees and elbows with the back straight. d. Holds the head at 45 degrees, and keeps the back straight

ANS: Raises head and arches back At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This is the Landau reflex, which persists until 1 1/2 years of age. The other responses are incorrect. See Figure 23-43.

In the assessment of a 1-month-old infant, the nurse notices a *lack of response to noise or stimulation*. The mother reports that in the last week he has been sleeping all the time, and when he is awake all he does is cry. The nurse hears that the *infant's cries are very high pitched and shrill*. What should be the nurse's appropriate response to these findings? . Refer the infant for further testing. b. Talk with the mother about eating habits. c. Do nothing; these are expected findings for an infant this age. d. Tell the mother to bring the baby back in 1 week for a recheck.

ANS: Refer the infant for further testing. A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, hyperirritability, and parent's report of significant change in behavior all warrant referral. The other options are not correct responses.

While obtaining a history of a 3-month-old infant from the mother, the nurse asks about the infant's *ability to suck and grasp the mother's finger*. What is the nurse assessing? a. Reflexes b. Intelligence c. CNs d. Cerebral cortex function

ANS: Reflexes Questions regarding reflexes include such questions as "What have you noticed about the infant's behavior," "Do the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.

A 21-year-old patient has a *head injury resulting from trauma* and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.

ANS: Reflexes will be normal. A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks his *left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step*. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis

ANS: Spastic hemiparesis With spastic hemiparesis, the arm is immobile against the body. There is flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder, which does not swing freely. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. See Table 23-6 for more information and for descriptions of the other abnormal gaits.

A patient has a *severed spinal nerve* as a result of trauma. Which of these statements is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component

ANS: The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. A dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance. That is, if one nerve is severed, most of the sensations can be transmitted by the spinal nerve above and spinal nerve below.

Which of these statements *concerning areas of the brain* is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

ANS: The hypothalamus controls temperature and regulates sleep. The hypothalamus is a vital area with many important functions: temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not the thalamus.

Which of these statements about the *peripheral nervous system* is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away by efferent fibers

ANS: The peripheral nerves carry input to the central nervous system by afferent fibers and away by efferent fibers. A nerve is a bundle of fibers outside the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by the efferent fibers.

A patient with *lack of oxygen to his heart will have pain in his chest and possibly the shoulder, arms, or jaw*. The nurse knows that the statement that best explains why this occurs is which of these? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

ANS: The sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere. The sensory cortex is arranged in a specific pattern, forming a corresponding "map" of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs are absent from the brain map, such as the heart, liver, and spleen. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt "by proxy" by another body part that does have a felt image. The other responses are not correct explanations.

During the assessment of an 80-year-old patient, the nurse notices that his *hands show tremors when he reaches for something and his head is always nodding*. There is no associated rigidity with movement. Which of these statements is most accurate? Not on powerpoint a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.

ANS: These are normal findings resulting from aging. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient *responds to pain by extending, adducting, and internally rotating his arms. His palms pronate and his lower extremities extend with plantar flexion*. Which of these statements about these findings is accurate? a. Indicates a lesion of the cerebral cortex. b. Indicates a completely nonfunctional brainstem. c. Is normal and will go away in 24 to 48 hours. d. Is a very ominous sign and may indicate brainstem injury.

ANS: This is a very ominous sign and may indicate brainstem injury. These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception the nurse decides to complete the test as quickly as possible. When the nurse *applies the sharp point of the pin on his arm several times*, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? Not on powerpoint a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

ANS: This is most likely the result of the *summation effect*. Let at least 2 seconds elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.

During an examination, the nurse notices *severe nystagmus in both eyes of a patient*. Which of these conclusions by the nurse is correct? a. Is a normal occurrence. b. May indicate disease of the cerebellum or brainstem. c. Is a sign that the patient is nervous about the examination. d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.

ANS: This may indicate disease of the cerebellum or brainstem. End-point nystagmus at an extreme lateral gaze occurs normally. The nurse should assess any other nystagmus carefully. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: *abduction and flexion of arms and legs; fanning of fingers, and curling of index and thumb in a C position followed by infant bringing in arms and legs to body*. What does the nurse know about this response? Not on powerpoint a. This response could indicate brachial nerve palsy. b. This reaction is an expected startle response at this age. c. This reflex should have disappeared between 1 and 4 months of age. d. This response is normal as long as the movements are bilaterally symmetric.

ANS: This reflex should have disappeared between 1 and 4 months of age. The Moro reflex is present at birth and disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a *light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out*, and the big toe shows dorsiflexion. The nurse interprets this result as: a. Negative Babinski sign, which is normal for adults. b. Positive Babinski sign, which is abnormal for adults. c. Clonus, which is a hyperactive response. d. Achilles reflex, which is an expected response.

ANS: a *positive Babinski's sign*, which is abnormal for adults. Dorsiflexion of the big toe and fanning of all toes is a positive Babinski's sign, also called "upgoing toes." This occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When *striking the Achilles and quadriceps*, the nurse is unable to elicit a reflex. The nurse's next response should be to: Not on powerpoint a. Ask the patient to lock her fingers and pull. b. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing. d. Document these reflexes as 0 on a scale of 0 to 4+.

ANS: ask the patient to lock her fingers and "pull." Sometimes the reflex response fails to appear. It is too soon to document this as "absent" reflexes. Try further encouragement of relaxation, varying the person's position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, ask the person to lock the fingers together and "pull."

Two parts of the *nervous system* are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral.

ANS: central and peripheral. The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.

A 32-year-old woman tells the nurse that she has noticed "*very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping*." This description suggests: a. Tics. b. Athetosis. c. Myoclonus. d. Chorea.

ANS: chorea. Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. See Table 23-5 for descriptions of athetosis, myoclonus, and tics.

The ability that humans have to perform *very skilled movements such as writing* is controlled by the: Not on powerpoint a. Basal ganglia. b. Corticospinal tract. c. Spinothalamic tract. d. Extrapyramidal tract.

ANS: corticospinal tract. Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, purposeful movements, such as writing. The corticospinal tract (also known as the pyramidal tract) is a newer, "higher" motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, *he tells the nurse that he is on a cruise ship and is 30 years old*. The nurse knows that this finding is indicative of: a. Great sense of humor. b. Uncooperative behavior. c. Inability to understand questions. d. Decreased level of consciousness.

ANS: decreased level of consciousness. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a *change in her husband's personality and ability to understand. He also cries and becomes angry very easily*. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe. a. Frontal b. Parietal c. Occipital d. Temporal

ANS: frontal The frontal lobe has areas concerned with personality, behavior, emotions, and intellectual function. The parietal lobe has areas concerned with sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is concerned with hearing, taste and smell.

The nurse is testing the function of *cranial nerve XI*. Which of these best describes the response the nurse should expect if the nerve is intact? The patient: a. Demonstrates the ability to hear normal conversation. b. Sticks out the tongue midline without tremors or deviation. c. Follows an object with his or her eyes without nystagmus or strabismus. d. Moves the head and shoulders against resistance with equal strength.

ANS: moves the head and shoulders against resistance with equal strength. These are the expected normal findings when testing cranial nerve XI (spinal accessory nerve): The patient's sternomastoid and trapezius muscles are of equal size; the person can rotate the head both ways forcibly against resistance applied to the side of the chin with equal strength; the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patient's ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is done to check CN III, IV, and VI.

A mother of a 1-month-old infant asks the nurse *why it takes so long for infants to learn to roll over*. The nurse knows that the reason for this is that: a. A demyelinating process must be occurring with her infant. b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. c. The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs. d. The spinal cord is controlling the movement because the cerebellum is not yet fully developed.

ANS: myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. The infant's sensory and motor development proceeds along with the gradual acquisition of myelin because myelin is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.

During an assessment of an 80-year-old patient, the nurse notices the following: *inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation*. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion.

ANS: normal changes due to aging. Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.

During an assessment of a 62-year-old man the nurse notices the patient has a *stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements*. These findings would be consistent with: a. Parkinsonism. b. Cerebral palsy. c. Cerebellar ataxia. d. Muscular dystrophy.

ANS: parkinsonism. The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism. See Table 23-8 for more information and for descriptions of the other options.

The nurse knows that *testing kinesthesia* is a test of a person's: a. Fine touch. b. Position sense. c. Motor coordination. d. Perception of vibration.

ANS: position sense. Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities. The other options are incorrect.

When the nurse asks a 68-year-old patient to *stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart*. The nurse would document this finding as a(n): a. Ataxia. b. Lack of coordination. c. Negative Homans sign. d. Positive Romberg sign.

ANS: positive Romberg sign. Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.

The area of the nervous system that is responsible for *mediating reflexes* is the: a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex.

ANS: spinal cord. The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves, and it mediates reflexes.

A patient is *not able to perform rapid alternating movements such as patting her knees rapidly*. The nurse should document this as: a. Ataxia. b. Astereognosis. c. Presence of dysdiadochokinesia. d. Loss of kinesthesia.

ANS: the presence of dysdiadochokinesia. Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person's ability to perceive passive movement of the extremities, or the loss of position sense.

During the history, a patient tells the nurse that *"it feels like the room is spinning around me."* The nurse would document this as: a. Vertigo. b. Syncope. c. Dizziness. d. Seizure activity.

ANS: vertigo. True vertigo is rotational spinning caused by neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Dizziness is a lightheaded, swimming sensation. Syncope is a sudden loss of strength or a temporary loss of consciousness. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.

The nurse is aware that intimate partner violence (IPV) screening should occur with which situation? A. when IPV is suspected B. when a woman has an unexplained injury C. as a routine part of each health care encounter D. when a history of abuse in the family is known

Ans: C Many nursing professional organizations have called for routine, universal screening for IPV to assist women in getting help for the problem.

During a home visit, the nurse notices that an older adult woman is caring for her bedridden husband. The woman states that this is her duty, she does the best she can, and her children come to help when they are in town. Her husband is unable to care for himself, and she appears thin, weak, and exhausted. The nurse notices that several of his prescription medication bottles are empty. this situation is best described by the term: A.physical abuse B. Financial neglect C. Psychological abuse D. Unintentional physical neglect

Ans: D Unintentional physical neglect may occur, despite good intentions, and is the failure of a family member or caregiver to provide basic goods or services.